FORMAT PENGKAJIAN ASUHAN KEPERAWATAN KEL
FORMAT PENGKAJIAN
ASUHAN KEPERAWATAN KELUARGA
STIKES HANG TUAH SURABAYA
A. PENGKAJIAN (TANGGAL : ..................................)
I.
Data Umum
1. Nama kepala keluarga : ......................................................................................................
2. Alamat dan telepon
: ......................................................................................................
3. Pekerjaan KK
: ......................................................................................................
4. Pendidikan KK
: ......................................................................................................
5. Komposisi keluarga
: ......................................................................................................
No.
Jenis
kel
Nama
Hub
kel –
KK
Status imunisasi
Umur
Dik
Polio
DPT
Hepatitis
Campak
Ket
Genogram :
1.
2.
3.
4.
5.
Tipe keluarga
: ......................................................................................................
Suku bangsa
: ......................................................................................................
Agama
: ......................................................................................................
Status sosial ekonomi : ......................................................................................................
Aktivitas rekreasi keluarga
II.
III.
.............................................................................................................................................
.............................................................................................................................................
Riwayat Dan Tahap Perkembangan Keluarga
1. Tahap perkembangan keluarga saat ini
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
2. Tugas perkembangan keluarga yang belum terpenuhi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3. Riwayat kesehatan keluarga inti
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
4. Riwayat kesehatan keluarga sebelumnya
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
Data Lingkungan
1. Karakteristik rumah
Denah rumah
2. Karakteristik tetangga dan komunitasnya
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3. Mobilitas geografis keluarga
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
4. Perkumpulan keluarga dan interaksi dengan masyarakat
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
5. Sistem pendukung keluarga
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
IV. Struktur Keluarga
1. Struktur peran
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
2. Pola komunikasi keluarga
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3. Struktur kekuatan keluarga
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
V.
Fungsi Keluarga
1. Fungsi ekonomi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
2. Fungsi mendapatkan status sosial
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3. Fungsi pendidikan
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
4. Fungsi sosialisasi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
5. Fungsi pemenuhan (perawatan/pemeliharaan) kesehatan
a. Mengenal masalah keluarga
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
b. Mengambil keputusan mengenai tindakan kesehatan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
c. Kemampuan merawat anggota keluarga yang sakit
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
d. Kemampuan keluarga memelihara/memodifikasi lingkungan rumah yang sehat
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
e. Kemampuan menggunakan fasilitas pelayanan kesehatan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
6. Fungsi religius
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
7. Fungsi rekreasi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
8. Fungsi reproduksi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
9. Fungsi afeksi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
VI. Stress Dan Koping Keluarga
1. Stressor jangka pendek dan panjang
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
2. Kemampuan keluarga berespon terhadap stressor
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3. Strategi koping yang digunakan
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
4. Strategi adaptasi disfungsional
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
VII. Pemeriksaan Kesehatan Tiap Individu Anggota Keluarga
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
VIII. Harapan Keluarga
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
Surabaya, .....................
Mahasiswa
(...............................)
B. DIAGNOSIS KEPERAWATAN KELUARGA
I.
Analisis Dan Sintesis Data
No.
Data
Masalah
Penyebab
II.
Daftar Diagnosis Keperawatan Yang Muncul
No
.
Diagnosa Keperawatan (PES)
III.
No
.
1
2
3
4
Penilaian (Skoring) Diagnosis Keperawatan
Dx. kep : ......................................................................................................................................
.......................................................................................................................................
Kriteria
Sifat masalah
- Tidak/kurang sehat
- Ancaman kesehatan
- Keadaan sejahtera
Kemungkinan masalah dapat diubah
- Mudah
- Sebagian
- Tidak dapat
Potensial masalah untuk dicegah
- Tinggi
- Cukup
- Rendah
Menonjolnya masalah
- Masalah berat harus segera ditangani
- Ada masalah, tetapi tidak perlu segera ditangani
- Masalah tidak dirasakan
Total skor
Skor Bobot Nilai
3
2
1
2
1
0
3
2
1
2
1
0
Pembenaran
1
2
1
1
Dx. kep : ......................................................................................................................................
.......................................................................................................................................
No
.
1
2
3
4
Kriteria
Sifat masalah
- Tidak/kurang sehat
- Ancaman kesehatan
- Keadaan sejahtera
Kemungkinan masalah dapat diubah
- Mudah
- Sebagian
- Tidak dapat
Potensial masalah untuk dicegah
- Tinggi
- Cukup
- Rendah
Menonjolnya masalah
- Masalah berat harus segera ditangani
- Ada masalah, tetapi tidak perlu segera ditangani
Skor Bobot Nilai
3
2
1
2
1
0
3
2
1
1
2
1
1
2
1
Pembenaran
- Masalah tidak dirasakan
Total skor
0
Dx. kep : ......................................................................................................................................
.......................................................................................................................................
No
.
1
2
3
4
Kriteria
Sifat masalah
- Tidak/kurang sehat
- Ancaman kesehatan
- Keadaan sejahtera
Kemungkinan masalah dapat diubah
- Mudah
- Sebagian
- Tidak dapat
Potensial masalah untuk dicegah
- Tinggi
- Cukup
- Rendah
Menonjolnya masalah
- Masalah berat harus segera ditangani
- Ada masalah, tetapi tidak perlu segera ditangani
- Masalah tidak dirasakan
Total skor
Skor Bobot Nilai
3
2
1
2
1
0
3
2
1
2
1
0
Pembenaran
1
2
1
1
Dx. kep : ......................................................................................................................................
.......................................................................................................................................
No
.
1
2
3
4
Kriteria
Sifat masalah
- Tidak/kurang sehat
- Ancaman kesehatan
- Keadaan sejahtera
Kemungkinan masalah dapat diubah
- Mudah
- Sebagian
- Tidak dapat
Potensial masalah untuk dicegah
- Tinggi
- Cukup
- Rendah
Menonjolnya masalah
- Masalah berat harus segera ditangani
- Ada masalah, tetapi tidak perlu segera ditangani
- Masalah tidak dirasakan
Total skor
Skor Bobot Nilai
3
2
1
2
1
0
3
2
1
2
1
0
IV. Prioritas Diagnosis Keperawatan
Prioritas
Diagnosis Keperawatan
Pembenaran
1
2
1
1
Skor
INTERVENSI KEPERAWATAN
No
.
Diagnosa
Keperawatan
Tujuan
Umum
Khusus
Kriteria
Standar
Intervensi
Evaluasi
Tanggal
No. DP
IMPLEMENTASI DAN EVALUASI
Implementasi
Evaluasi
Paraf
ASUHAN KEPERAWATAN KELUARGA
STIKES HANG TUAH SURABAYA
A. PENGKAJIAN (TANGGAL : ..................................)
I.
Data Umum
1. Nama kepala keluarga : ......................................................................................................
2. Alamat dan telepon
: ......................................................................................................
3. Pekerjaan KK
: ......................................................................................................
4. Pendidikan KK
: ......................................................................................................
5. Komposisi keluarga
: ......................................................................................................
No.
Jenis
kel
Nama
Hub
kel –
KK
Status imunisasi
Umur
Dik
Polio
DPT
Hepatitis
Campak
Ket
Genogram :
1.
2.
3.
4.
5.
Tipe keluarga
: ......................................................................................................
Suku bangsa
: ......................................................................................................
Agama
: ......................................................................................................
Status sosial ekonomi : ......................................................................................................
Aktivitas rekreasi keluarga
II.
III.
.............................................................................................................................................
.............................................................................................................................................
Riwayat Dan Tahap Perkembangan Keluarga
1. Tahap perkembangan keluarga saat ini
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
2. Tugas perkembangan keluarga yang belum terpenuhi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3. Riwayat kesehatan keluarga inti
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
4. Riwayat kesehatan keluarga sebelumnya
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
Data Lingkungan
1. Karakteristik rumah
Denah rumah
2. Karakteristik tetangga dan komunitasnya
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3. Mobilitas geografis keluarga
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
4. Perkumpulan keluarga dan interaksi dengan masyarakat
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
5. Sistem pendukung keluarga
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
IV. Struktur Keluarga
1. Struktur peran
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
2. Pola komunikasi keluarga
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3. Struktur kekuatan keluarga
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
V.
Fungsi Keluarga
1. Fungsi ekonomi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
2. Fungsi mendapatkan status sosial
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3. Fungsi pendidikan
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
4. Fungsi sosialisasi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
5. Fungsi pemenuhan (perawatan/pemeliharaan) kesehatan
a. Mengenal masalah keluarga
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
b. Mengambil keputusan mengenai tindakan kesehatan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
c. Kemampuan merawat anggota keluarga yang sakit
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
d. Kemampuan keluarga memelihara/memodifikasi lingkungan rumah yang sehat
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
e. Kemampuan menggunakan fasilitas pelayanan kesehatan
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
6. Fungsi religius
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
7. Fungsi rekreasi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
8. Fungsi reproduksi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
9. Fungsi afeksi
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
VI. Stress Dan Koping Keluarga
1. Stressor jangka pendek dan panjang
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
2. Kemampuan keluarga berespon terhadap stressor
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
3. Strategi koping yang digunakan
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
4. Strategi adaptasi disfungsional
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
VII. Pemeriksaan Kesehatan Tiap Individu Anggota Keluarga
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
VIII. Harapan Keluarga
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
Surabaya, .....................
Mahasiswa
(...............................)
B. DIAGNOSIS KEPERAWATAN KELUARGA
I.
Analisis Dan Sintesis Data
No.
Data
Masalah
Penyebab
II.
Daftar Diagnosis Keperawatan Yang Muncul
No
.
Diagnosa Keperawatan (PES)
III.
No
.
1
2
3
4
Penilaian (Skoring) Diagnosis Keperawatan
Dx. kep : ......................................................................................................................................
.......................................................................................................................................
Kriteria
Sifat masalah
- Tidak/kurang sehat
- Ancaman kesehatan
- Keadaan sejahtera
Kemungkinan masalah dapat diubah
- Mudah
- Sebagian
- Tidak dapat
Potensial masalah untuk dicegah
- Tinggi
- Cukup
- Rendah
Menonjolnya masalah
- Masalah berat harus segera ditangani
- Ada masalah, tetapi tidak perlu segera ditangani
- Masalah tidak dirasakan
Total skor
Skor Bobot Nilai
3
2
1
2
1
0
3
2
1
2
1
0
Pembenaran
1
2
1
1
Dx. kep : ......................................................................................................................................
.......................................................................................................................................
No
.
1
2
3
4
Kriteria
Sifat masalah
- Tidak/kurang sehat
- Ancaman kesehatan
- Keadaan sejahtera
Kemungkinan masalah dapat diubah
- Mudah
- Sebagian
- Tidak dapat
Potensial masalah untuk dicegah
- Tinggi
- Cukup
- Rendah
Menonjolnya masalah
- Masalah berat harus segera ditangani
- Ada masalah, tetapi tidak perlu segera ditangani
Skor Bobot Nilai
3
2
1
2
1
0
3
2
1
1
2
1
1
2
1
Pembenaran
- Masalah tidak dirasakan
Total skor
0
Dx. kep : ......................................................................................................................................
.......................................................................................................................................
No
.
1
2
3
4
Kriteria
Sifat masalah
- Tidak/kurang sehat
- Ancaman kesehatan
- Keadaan sejahtera
Kemungkinan masalah dapat diubah
- Mudah
- Sebagian
- Tidak dapat
Potensial masalah untuk dicegah
- Tinggi
- Cukup
- Rendah
Menonjolnya masalah
- Masalah berat harus segera ditangani
- Ada masalah, tetapi tidak perlu segera ditangani
- Masalah tidak dirasakan
Total skor
Skor Bobot Nilai
3
2
1
2
1
0
3
2
1
2
1
0
Pembenaran
1
2
1
1
Dx. kep : ......................................................................................................................................
.......................................................................................................................................
No
.
1
2
3
4
Kriteria
Sifat masalah
- Tidak/kurang sehat
- Ancaman kesehatan
- Keadaan sejahtera
Kemungkinan masalah dapat diubah
- Mudah
- Sebagian
- Tidak dapat
Potensial masalah untuk dicegah
- Tinggi
- Cukup
- Rendah
Menonjolnya masalah
- Masalah berat harus segera ditangani
- Ada masalah, tetapi tidak perlu segera ditangani
- Masalah tidak dirasakan
Total skor
Skor Bobot Nilai
3
2
1
2
1
0
3
2
1
2
1
0
IV. Prioritas Diagnosis Keperawatan
Prioritas
Diagnosis Keperawatan
Pembenaran
1
2
1
1
Skor
INTERVENSI KEPERAWATAN
No
.
Diagnosa
Keperawatan
Tujuan
Umum
Khusus
Kriteria
Standar
Intervensi
Evaluasi
Tanggal
No. DP
IMPLEMENTASI DAN EVALUASI
Implementasi
Evaluasi
Paraf